Voluntary Registration for People with Access and Mobility Needs

The People with Access and Mobility Needs Registry is a voluntary program for full and part-time residents of Warren County. The registry is designed for residents that may need additional assistance during an emergency. These needs include but are not limited to: temporary limitations, chronic conditions, special healthcare needs, and language barriers. The information that you provide may help responders meet your needs during an emergency. For additional questions call 518-761-6580 or email snr@warrencountyny.gov

Fields marked with an asterisk (*) are required.

Registrant Details

*First Name

Middle Initial

*Last Name

*Date of Birth (MM-DD-YYYY) Weight

Physical Address

*House Number *Street Apt.

*City *Zip

Is your physical address also your mailing address?

Yes No

Mailing Address

Address

City State Zip

Primary Phone

Alternate Phone

TDD/TDY (for hearing impaired)

Yes No

Email Address

Email Address (Confirm)

Are you capable of receiving communication in English?

Yes No

What language(s) can you receive communications in?

Are you out of state for a period of time?

Yes No

When will you be out of state?

Emergency Contact

Person to Contact in an Emergency

Primary Phone

Alternate Phone

Life Support Systems

Oxygen

Yes No

Tank or Concentrator?

Tank

Concentrator

Dialysis

Yes No

Home or Clinic?

Clinic

Home

Electrical

Please check any electrical devices that you use:

Pacemaker

Defibrillator

Medicine that requires refrigeration

Do you require a 24 hour caregiver?

Yes No

Mobility

Are you confined to a bed?

Yes No

Do you need assistance walking?

Yes No

Mobility Aids

Please check any mobility aids that you use:

Wheelchair

Walker/cane

Crutches

Assistive Animal

Prosthesis

Other

Sensory, Cognitive and Psychiatric Conditions

Please check all conditions that apply:

Visually impaired

Legally blind

Hard of Hearing

Use hearing aids

Deaf

Seizure disorder

Speech impaired

Non-verbal

Cognitively-Developmentally delayed

Autism Spectrum Disorder

Alzheimer’s / Dementia

Psychiatric Condition

Other

Evacuation Requirements

If I have to evacuate I will go to

Family Friend Shelter

First Name

Last Name

Phone

Do you need assistance evacuating?

Yes No

Have you arranged for someone to help you evacuate?

Yes No

Appropriate transportation type needed

Standard vehicle (car, bus) Wheelchair Capable Ambulance

Pets

Do you have pets?

Yes No

Type of Pets

Cat(s) – Amount

Dog(s) – Amount

Bird(s) – Amount

Other Pets

Have you arranged for your pet(s) to be cared for in the event you need to evacuate?

Yes No

Will your pet(s) need to be evacuated and sheltered?

Yes No

Is there any additional information we should be aware of?

By registering, I hereby consent and pre-authorize emergency response personnel
to enter my home during search and rescue operations if necessary to assure my safety and welfare
during an emergency or natural disaster.